Provider Demographics
NPI:1952387227
Name:ANTOSZYK, MARK D (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ANTOSZYK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 BLACKSTONE CT NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-9071
Mailing Address - Country:US
Mailing Address - Phone:704-262-9206
Mailing Address - Fax:704-783-2527
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2927
Practice Address - Country:US
Practice Address - Phone:704-783-1689
Practice Address - Fax:704-783-2527
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC157768367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052179Medicaid
2603920Medicare ID - Type Unspecified
NC8052179Medicaid